The practical value of biologics registries in Africa and Middle East: challenges and opportunities

Biologics, including tumor necrosis factor (TNF) inhibitors, are increasingly used for the treatment of inflammatory conditions such as rheumatoid arthritis (RA), psoriatic arthritis, and ankylosing spondylitis. The efficacy of these drugs has been demonstrated in randomized controlled trials (RCTs). However, these studies are conducted in controlled environments, and the results may not necessarily reflect clinical outcomes in daily clinical practice. In Europe and other western countries, numerous biologics registries that enroll and monitor patients receiving biologics have been established. These registries follow patients irrespective of whether they continue with the initial biologic drug. Thus, real-life efficacy data from these registries can be used to assess the long-term safety of biologics through longitudinal studies. In Africa and Middle East (AFME), such registries currently exist only in Morocco and South Africa. In light of the increasing availability of biologics and scarcity of long-term safety data of these agents in the AFME population, there is a need to establish biologics registries in other countries across the region. This review discusses the value of biologics registries versus RCTs as well as safety and efficacy data from observational studies presented as lessons from well-established biologics registries. In addition, the rationale for establishing such registries in the AFME region is also presented.     

Therapeutic challenges in the management of gout in the elderly

Gout is the most common inflammatory arthritis in the elderly population. Management in the elderly requires special consideration. Physiologic changes associated with aging and co-morbidities make the elderly prone to adverse effects of drugs otherwise successfully used in younger counterparts. Use of colchicine, non-steroidal anti-inflammatory drugs, and urate-lowering therapies may be restricted in those with limited renal reserve. Corticosteroids are safe alternatives for short-term use in acute gout. Elderly patients need laboratory monitoring for side effects more frequently than usual. Non-pharmacologic measures such as dietary modifications, regular exercise, and ice therapy should be considered vital adjunctive treatments. A brief review of future therapies is also discussed.     

Diabetes in Africa: epidemiology, management and healthcare challenges

Diabetes is an increasing problem in sub-Saharan Africa. Type 2 diabetes, the most common form, is becoming more prevalent owing to rising rates of obesity, physical inactivity and urbanisation. Type 1 diabetes exists in two major forms in the region: type 1A or autoimmune and type 1B or ketosis-prone type 2 diabetes. At present there are scanty epidemiological data on either. The current morbidity of diabetes is primarily due to the high rates of microvascular complications, while macrovascular complications, once rare, are becoming more common, particularly in the urban setting. Further, despite the HIV epidemic, the total number of people with diabetes in the region is expected to grow because of changing demography. A concerted multisectoral effort will be critical to ensuring improvement in healthcare delivery for people with diabetes in the region.     

Pharmacogenomics: challenges and opportunities

The outcome of drug therapy is often unpredictable, ranging from beneficial effects to lack of efficacy to serious adverse effects. Variations in single genes are 1 well-recognized cause of such unpredictability, defining the field of pharmacogenetics (see Glossary). Such variations may involve genes controlling drug metabolism, drug transport, disease susceptibility, or drug targets. The sequencing of the human genome and the cataloguing of variants across human genomes are the enabling resources for the nascent field of pharmacogenomics (see Glossary), which tests the idea that genomic variability underlies variability in drug responses. However, there are many challenges that must be overcome to apply rapidly accumulating genomic information to understand variable drug responses, including defining candidate genes and pathways; relating disease genes to drug response genes; precisely defining drug response phenotypes; and addressing analytic, ethical, and technological issues involved in generation and management of large drug response data sets. Overcoming these challenges holds the promise of improving new drug development and ultimately individualizing the selection of appropriate drugs and dosages for individual patients.     

Tuberculosis in sub-Saharan Africa: opportunities, challenges, and change in the era of antiretroviral treatment

Rapid scale-up of antiretroviral treatment programmes is happening in Africa, driven by international advocacy and policy directives and supported by unprecedented donor funding and technical assistance. This welcome development offers hope to millions of HIV-infected Africans, among whom tuberculosis is the major cause of serious illness and death. Little in the way of HIV diagnosis or care was previously offered to patients with tuberculosis, by either national tuberculosis or AIDS control programmes, with tuberculosis services focused exclusively on diagnosis and treatment of rising numbers of patients. Tuberculosis control in Africa has yet to adapt to the new climate of antiretroviral availability. Many barriers exist, from drug interactions to historic differences in the way that tuberculosis and HIV are perceived, but failure to successfully integrate HIV and tuberculosis control will threaten the viability of both programmes. Here, we review tuberculosis epidemiology in Africa and policy implications of HIV/AIDS treatment scale-up.     

The road to rheumatoid arthritis prevention: challenges and opportunities

Clinical Rheumatology - Rheumatoid arthritis (RA) is the most prevalent cause of chronic arthritis worldwide and contributes substantial health burden and socioeconomic costs, issues that are...     

The human microbiome: opportunities and challenges for clinical care

There is a growing appreciation of the importance of the human microbiome to our normal physiology. This complex microbial ecosystem plays a range of roles, including influencing the development and function of our immune systems, providing essential nutrients, regulating metabolism and protecting us from opportunistic infections. Our increasing understanding of these processes is due, to a large extent, to the development of high‐throughput sequencing technologies, providing for the first time a means by which complex microbial dynamics can be detailed. There is also a growing recognition that disruption of commensal microbiota, a phenomenon known as dysbiosis, is associated with several common disorders, including inflammatory bowel disease, type 2 diabetes and oncogenesis. Further, where innate immunity fails to protect us, the microbial communities that colonise the external surfaces of our bodies represent a ready source of infection. This review discusses the mechanisms that govern our interaction with our resident microbiota, both in health and disease, the technological advances that allow us to gain insight into these relationships, and the way in which our growing understanding can inform clinical practice.     

Immunotherapy for polyomaviruses: opportunities and challenges

Polyomaviruses are small DNA viruses present in mammals and birds, and in 1953 the first one to be described was murine polyomavirus. It was not until 1971 that the first two human polyomaviruses (HPyVs), BK virus and JC virus, were discovered and found to be common in humans, but only associated with disease in severely immunosuppressed patients. Since 2007, seven new HPyVs have been identified: KI polyomavirus, WU polyomavirus, Merkel cell polyomavirus, HPyV6, HPyV7, trichodyplasia spinulosa polyomavirus and HPyV9. Notably, Merkel cell polyomavirus was detected in Merkel cell cancer, a tumor mainly found in elderly and immunocompromised individuals, while trichodyplasia spinulosa polyomavirus was found in trichodyplasia spinulosa, a skin disorder observed only in immunosuppressed individuals. Consequently, many polyomaviruses cause problems in immunosuppressed individuals. This review deals with these issues, and the potential of the capsid protein VP1 to form virus-like particles for use as vaccines against polyomavirus infections.